Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions. In doing so, the treating physician may unwittingly provide support for specious claims of illness or injury by conferring official diagnoses, or by delivering treatments that transform the patient from a pretender into a person with a genuine, although iatrogenic, medical problem (eg, via adrenalectomy, pancreatectomy, serial amputation).1-3

Forensic psychiatrists may be called on during civil or criminal litigation to help determine the authenticity of a patient’s apparent medical illnesses or injuries. Even when a patient’s medical deceptions are proved beyond any doubt, the forensic psychiatrist may be asked to help determine the underlying psychological processes that led to the deception. In other cases, the patient may pursue civil damages from the treating physician for performing unnecessary interventions, and the forensic psychiatrist is asked to weigh in on the culpability of a colleague for failing to detect the deception.4-6

The forensic psychiatrist faces 2 synergistically related obstacles. First, in contrast to malingering, there is little empirical research on the nature of factitious disorder, its underlying psychological processes, or ways to assess it. Second, despite the aforementioned lack of scientific evidence, DSM-IV-TR provides an artificially definitive classification system for patients with inauthentic illness behavior, to which the examiner’s conclusions are expected to correspond.

Consciousness, intentionality, and insanity in DSM

Many decisions in legal proceedings boil down to the question of consciousness and intention. Was the defendant aware of what he or she was doing, did he intend to do it, and was the motive for doing it reasonable? Conveniently, DSM-IV-TR categories dealing with inauthentic illness behavior (ie, behaving as if one is sick when one really is not) neatly address these questions.

The DSM somatoform disorders category specifies 5 disorders for which inauthentic illness behavior presumably is neither conscious nor intentional. These are somatization disorder, hypochondriasis, conversion disorder, pain disorder, and undifferentiated somatoform disorder. It specifies another category—factitious disorder—in which inauthentic illness behavior is consciously and intentionally produced. This category is reserved for people whose motives appear to reflect severe psycho-pathology (eg, a person who would agree to prophylactic double mastectomy just to get attention from medical personnel, friends, and coworkers).7DSM also recognizes cases of malingering (as a “V” code, not a true psychiatric diagnosis) in which the inauthentic medical behavior is conscious, intentional, and reflects more comprehensible motives (eg, faking a fall in a retail store to get millions of dollars in compensation for medical and emotional damages).

Without detailing the full DSM diagnostic criteria sets for these disorders and their relations, the following is a summary of how DSM instructs psychiatrists to diagnose cases of inauthentic illness behavior:

1. In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caught on video, evidence from a room search), diagnose a somatoform disorder.

2. If there is traditional forensic evidence of overt medical deception, diagnose malingering or factitious disorder.

3. If there is any significant material or instrumental benefit from the intentional medical deception (eg, financial settlement, disability determination, access to narcotic medicine), diagnose malingering.

These 3 categories are mutually exclusive, and there is no hedging.

Anyone with even minimal experience in dealing with patients with complex and suspicious medical histories recognizes how inadequate and oversimplified DSM directives are. The criteria make it virtually impossible to diagnose a case as anything other than a somatoform disorder when intentionality cannot be proved with traditional forensic evidence. There are no psychological tests of consciousness, and even strong evidence of a relationship between the occurrence of inauthentic illness behavior and tangible benefits would not suffice to overrule a somatoform diagnosis. Thus, in cases dominated by subjective complaints like pain, fatigue, and weakness, it is virtually impossible to definitively diagnose factitious disorder or malingering.